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Dercum 4/22/2014 4:00:39131, SAN JO�eJIN COUNTY ENVIRONMENTAL HEAL DEPARTMENT Report#5021 <br /> Ron by eta Pagel <br /> Facility Information as of 4/22/2014 <br /> Record Selection Criteria: Facility ID FA0010498 <br /> Make changes/corrections In RED Ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN/Fed Tax ID <br /> Owner ID OW0008498 Case Number: H08227 New Owner ID <br /> Owner Name VILLALOBOS, CANDELARIO <br /> Owner DBA DEL RIO WEST PALLET <br /> Owner Address 3845 S EL DORADO ST <br /> STOCKTON, CA 95206 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-983-8215 <br /> Mailing Address 3845 S ELDORADO ST <br /> STOCKTON, CA 95206 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0010498 10,183,601 <br /> Facility Name DEL RIO WEST PALLET <br /> Location 3845 S EL DORADO ST <br /> STOCKTON, CA 95206 <br /> Phone 209-983-8215 <br /> Mailing Address 3845 S EL DORADO ST <br /> STOCKTON, CA 95206 <br /> Care of <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District 001 -VILLAPUDUA Fax <br /> APN 17525057 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION �1 r <br /> Contact Name L, <br /> Title <br /> Day Phone - .�11 <br /> Night Phone S / <br /> ACCOUNTS RECEIVABLE FILE INFORMATION + <br /> Account ID AR0017498 nYYY��� n1 1 ((t Account ID: <br /> Mail Invoices to Owner ��ll. 1.Mail Invoices to: r / Facility I Account <br /> Account Name VILLALOBOS, CANDELARIO l �c` S eU e o^a) L u%✓e ' <br /> Account Balance as of 4/22/2014: $248.50 L y/` �/ y ? <br /> C O I rti / / 7�:10 7�o G � c �Y-"O JJc� G <br /> Circle One) <br /> Transfer to Ac /InacNe <br /> P� Ele en Description Record ID Employee antl Name Status New Owner? Delete <br /> 1920-HMBP-Common Materials PR0520388 EE0009817-ROBERT LOPEZ Active Y N A I D <br /> HAZ MAT BUSINESS PLAN AUTHORIZATION PR0512786 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PR0510498 EEOOOOOOO-HAZ MAT SJC OES Inactive Y N A I D <br /> 4740-WASTE TIRE SITE-EXEMPT PR0526203 EE0009000-HARPRIT MATTU Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO533402 Inactive Y N A I D - <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andor project specdic,PHSIEHD hourly charges associated with this facility <br /> or activity will be billed to the party Identified as the OWNER on this form. Ialso certify that all operations will be performed in accordance with all applicable Ordinance Codes andor Standards and State ands <br /> Federal Laws. ^ w nQ L ' ��D <br /> r7 ROC r�ur <br /> APPLICANT'S SIGNATU Date <br /> Program Records to be TRANSFERED: `$25.00= Amount Paid Date Il <br /> Water System to be TRANSFERED: Amount Paid ate <br /> Payment pe Check Number Re ' <br /> REHS: -AL2_ Date7/9 <br /> /�f- / Account out: Date / /� <br /> COMMENTS: � I���D �'-/tL <br /> T ' e—CtS � / �1\,C�nq T� � �II//� �o � clZ � ave 7, 11 <br />